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By all accounts, 2008 was a tough year for nursing homes.

Tighter inspections have led to an increase in admission suspensions and closures at skilled nursing facilities across the state. Governor Bredesen was successful in seeing the Long Term Care Community Choices Act pass in the Legislature thus requiring nursing homes to rethink the way they do business. And to top off a banner year, the Centers for Medicare & Medicaid Services released a quality report card in December that firmly placed Tennessee's nursing homes at the bottom of the barrel. Throughout it all, the state's facilities were caught up in the glare of the media spotlight as the public demanded more transparency.

Despite the black eyes, there seems to be a sense of anticipation that the state's long-term care landscape is evolving and will ultimately live up to the promise of truly offering a full continuum of care for the elderly and disabled.

As executive director for the Tennessee Association of Homes & Services for the Aging, Carrie Ermshar represents the full spectrum of care and lauds the promise held by the Community Choices Act. "It's a huge step in the right direction," she said of the law. "There's a lot of detail still to be worked out, but the fundamental change that the passage of the bill brought was opportunity for more options and choices as we age. That's a very good thing.

"Individuals are going to need different things. We can't continue to box people in," she continued. "The nursing home will have to evolve into a facility to care for the frailest of the frail … that's what they were originally intended to do ... that's what they're good at doing."

Patti Killingsworth, chief of long-term care for TennCare, said the act is "a plan for helping us fundamentally restructure how we deliver long-term care in the state. More than anything else," she noted, "it's about expanding access to care in your own home or in the community. That said, we recognize nursing homes are an important part of the care continuum."

By addressing issues within the community from offering in-home services to transportation options to adult daycare centers, many seniors can prolong the time they are able to live at home. Killingsworth said that even for those who need residential options, there are other choices besides nursing homes. In addition to assisted living programs, she said the state is exploring adult care homes, which typically support four-five residents in a residential setting so that it's much more homelike and less institutional. Although not yet available in Tennessee, "it's something we plan to pursue over the course of the next year," she said.

In order to move forward with plans to expand services in the community, however, TennCare needs federal approval of a waiver amendment that would give the Bureau much greater flexibility in the Home and Community Based Services (HCBS) program.

"We've asked the state be given the authority to serve as many as we can serve depending on resources and capacity in the community," Killingsworth said. "For every person who chooses cost effective care at home, we know we can serve more people."




Currently, the state's HCBS waiver is capped at 6,000 people. Killingsworth said the state was on course to hit that maximum by the end of the current fiscal year. She noted TennCare began the negotiation process with CMS in July 2008 with the hope of gaining approval before the end of last calendar year.

"Obviously that didn't happen," she said, adding, "We're working very hard to get the waiver amendment so that we can do these wonderful things people wanted us to do but which require federal approval."

In the meantime, groundwork for new programming is being laid while the state awaits the green light. While waiting for the inevitable changes, the nursing home industry must sort through the last few months of bad news and decide how to best move forward.

Ermshar sees the staffing issue as the most critical facing the industry and the key to attaining higher quality levels. "As an industry, we have got to be able to attract more people," she stressed, adding that it is tough to retain a qualified workforce on $6 an hour.

"The nursing home is going to become a much more acute care model," Ermshar said. "The reimbursement for nursing homes is going to shift to an acuity-based model. Realistically a nursing home will be paid to take care of that sicker patient. Now, will that be enough to take care of staffing levels? That remains to be seen," she said.

Ermshar and her colleagues have also called for a revamping of the survey and certification system.

"Ultimately, I have to believe that we all want to be at the same place, and that would be quality service to the elderly of Tennessee," she said. "However, there are huge obstacles to how we're going to achieve that, and one of the biggest obstacles to that is the subjective regulatory process with which nursing homes are screened.

"While the regulations have not necessarily changed, what has changed is the level of enforcement across the state," she continued, adding, "the level of enforcement, as well as the interpretation."

Killingsworth also noted the federal regulations have an element of subjectivity that comes with human inspectors applying standards. She said the information compiled by CMS in the recent ratings was valuable but that it doesn't present the whole picture of a nursing home. "I do believe we have … for the most part … good, quality facilities that offer quality care," she said. "I think that over time, CMS will probably continue to improve this ranking system, and I also think facilities will respond to the information," she noted.

Another issue that must be addressed, Ermshar said, is that the long-term care sector is too often looked at as an afterthought in the healthcare industry and needs to take steps to improve their visibility.

"We have to work on bridging tighter relationships between your acute care and post-acute care environments. That's truly an equal responsibility between hospitals and nursing homes."

She added the way to begin that dialogue is by picking up the phone and getting to know each other and know what services are available in the long-term continuum.

"It is so important that providers and their staff educate themselves about the options that exist so they can share with individuals," agreed Killingsworth. "Too often, we send someone to a nursing home not because they couldn't go home but because we didn't plan well enough to have home and community services in place. Discharge planning should begin the day they are admitted."

Ermshar hopes that the upheavals of 2008 will lead to positive changes in 2009. She said the bottom line is that the population is demanding a different model of care.

"As a delivery system, we've got to change to meet those needs. The opportunity the New Year gives us is embracing change. Are we ready? If we're not, we better be. In the future, there will be two types of facilities – the excellent and the non-existent."

Tags:

Carrie Ermshar, Long Term Care Community Choices Act, long-term care continuum, nursing homes, Patti Killingsworth, TennCare, Tennessee Association of Homes & Services for the Aging, TNAHSA

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